Vignette-Based Assessment Tool Helps to Gauge Provider Referral Practices

Research points to ​​unwarranted variation in optometric referral decision-making.

Eye care providers make numerous case management decisions every day, including whether to refer a patient to secondary care or manage treatment in the optometry clinic. Keeping referral practices consistent independent of a clinician’s experience level may well provide smooth ongoing patient care and efficient use of resources. Currently, more is known about referral quantity and quality in general medicine than for optometry.

An investigation by researchers in the UK found recently-qualified optometrists were considerably more likely to refer than seasoned practitioners (P =.004), and referral rate decreased along with the number of years since a clinician’s qualification, that is, joining the register of UK’s General Optical Council (P =.006), according to data published in Journal of Optometry. Investigators designed an online, scenario-based set of vignettes to evaluate differences in referring practices by 3 groups of providers; 31 veteran qualified optometrists (QO), 18 newly-qualified optometrists (NQO), and 11 optometrists who were completing the period of supervised practice before becoming qualified — pre-registered optometrists (PRO).

The set of 10 vignettes did not include lists or multiple choice to eliminate a prompting, or leading effect. For instance, a scenario began “You are about to examine a 45-year-old patient named Paul who is new to the practice. You know nothing about him and are starting with a blank record. This is his first test for 20 years.” Participants then stated in their own words what actions or test they would choose. More information was presented, such as test results, and the respondent chose the next test. After the third action, participants could make a management decision or call for another test.

For 6 months after the first set of vignettes, QOs could take advantage of Continuing Education and Training (CET), NQOs took part in a two-day clinical training course, and PROs could access supervisor mentorship. Then, participants completed another 10 vignettes, and scores were compared with the first set to generate a sum vignette score change (VSC). There was little change in referral practices after CET for experienced QOs (P =.37). There was also no significant difference in VSC between the 3 groups (P =.997). For the second set of vignettes, mean rank score change was 30.4 in the QO and NQO cohorts, and 30.9 in the PRO group.

The scenarios covered anterior eye, cataract, refraction, retina, and other topics customary in primary care. Vignette resolutions either leaned definitely to or against referral, or involved uncertain, “gray” referral choice.

Less-experienced optometrists may lack confidence in making referral decisions, the investigation speculates. To improve referral appropriateness and quality, researchers recommend that ophthalmologists offer regular return communication — a positive “feedback loop.”

Data was gathered between February 2015 and October 2016. Limitations of this analysis included a small sample size which may have resulted in insufficient power, and a possible selection bias that occurred as skilled and confident optometrists more often chose study participation. 

“Despite the study being underpowered, the results suggest that unwarranted variation in optometric referral decision-making exists and that it is possible to identify underperformance,” the investigation notes.

Disclosures: The vignette assessment interface was supported by grants from the Central Optical Fund, and Bexley, Bromley and Greenwich Local Optical Committee. 


Parkins DJ, Shah B, Benwell MJ, et al. Design and use of vignettes to investigate referral decision-making by optometrists. J Optom. 2021;14(1):69–77. doi:10.1016/j.optom.2020.09.004